Cardiology

Question 1

How is symptomatic bradycardia managed if atropine fails?

Answer 1

External pacing is used for symptomatic bradycardia if atropine fails

Question 2

Why shouldn’t verapamil be prescribed along with a beta blocker for angina?

Answer 2

While verapamil is a calcium channel blocker it should not be prescribed alongside a beta-blocker due to the risk of complete heart block.

Question 3

When should ivabradine (a long-acting nitrate) be considered in a patient with angina?

Answer 3

Long-acting nitrates should not generally be used as monotherapy and should only be considered as an add-on if the patient cannot tolerate the combination of a beta-blocker and calcium channel blocker.

Question 4

When is fibrinolytic therapy considered for an acute presentation of a STEMI?

Answer 4

Fibrinolytic therapy should only be used if there is a significant delay in being able to provide PCI.
PCI should be chosen if it can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI).

Question 5

What is the chief anatomical indication for a CABG?

Answer 5

The chief anatomical indications for CABG are the presence of triple-vessel disease or severe left main stem artery stenosis.

Question 6

How long do NICE recommend we wait following a myocardial infarction before prescribing a phosphodiesterase type 5 inhibitor?

Answer 6

The correct answer is 6 months. According to the National Institute for Health and Care Excellence (NICE) guidelines, it is recommended to wait at least 6 months after a myocardial infarction before prescribing a phosphodiesterase type 5 inhibitor such as sildenafil. This is because there is an increased risk of cardiovascular events in patients who have recently experienced a myocardial infarction, and phosphodiesterase type 5 inhibitors can potentially exacerbate this risk by causing systemic vasodilation and reducing blood pressure.

Question 7

What is a normal corrected QT interval? What is prolonged?

Answer 7

less than 430 ms in males and 450 ms in females.
Prolonged would me > 450ms men and >460ms in women

Question 8

Following ACS, what are the five drugs patients should be discharged with?

Answer 8

dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin

Question 9

What is the criteria to treat stage 1 hypertension?

Answer 9

treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater

Question 10

When is bioprosthetic heart valve offered as opposed to mechanical?

Answer 10

According to UK guidelines, this intervention is recommended for patients aged >65 years or younger patients not wishing to take lifelong anticoagulation. Bioprosthetic valves have the advantage of not requiring long-term anticoagulation, unlike mechanical valves, and are generally preferred in older patients due to their better hemodynamic properties and lower risk of thromboembolic complications.
Younger patients given a biopresthetic valve would also be more at risk of biodegradation.

Question 11

In what situation would you prioritise giving shocks before CPR in a cardiac arrest?

Answer 11

Although patients in VF/pulseless VT should receive one shock followed by two minutes of CPR, if they are witnessed having the cardiac arrest and are monitored (e.g. coronary care unit, critical care unit, catheter laboratory) then they should receive a maximum of three successive shocks instead. Chest compressions would then follow and CPR would be continued for 2 minutes.

Question 12

First-line treatment for regular broad complex tachycardias without adverse features?
What would be considered as adverse features?

Answer 12

IV amiodarone

shock, syncope, myocardial ischaemia or heart failure

Question 13

What drug is contraindicated in ventricular tachycardia?

Answer 13

Verapamil is contraindicated in VT as intravenous administration of a calcium channel blocker can precipitate cardiac arrest.

Question 14

How do you treat acute AF which is haemodynamically unstable?

Answer 14

Acute presentation of atrial fibrillation: if signs of haemodynamic instability (e.g. hypotension, heart failure) → electrical cardioversion, as per the peri-arrest tachycardia guidelines

Question 15

When should synchronised vs unsynchronised DC cardioversion be used?

Answer 15

Unsynchronised DC cardioversion should be used in patients with pulseless VT/VF or unstable polymorphic VT, where synchronised cardioversion is impossible. A patient with tachyarrhythmia with discernible R waves should have synchronised DC conversion.

Question 16

What are the indications of synchronised DC cardioversion?

Answer 16

Tachycardia with haemodynamic instability, signs of myocardial ischaemia, heart failure or syncope are indications for synchronised DC cardioversion.

Question 17

What is the criteria to have ivabradine as part of 3rd line treatment option in HF?

Answer 17

criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%

Question 18

What is the indication for cardiac resynchronisation therapy in HF?

Answer 18

a widened QRS (e.g. left bundle branch block) complex on ECG

Question 19

What vaccinations are offered to HF patients?

Answer 19

offer annual influenza vaccine
offer one-off pneumococcal vaccine
- adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years

Question 20

What are the parameters for the different stages of hypertension?

Answer 20

Stage 1 hypertension Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
Stage 2 hypertension Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
Severe hypertension Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg

Question 21

What three heart structural disorders cause a pan systolic murmur?

Answer 21

This type of murmur is heard with tricuspid and mitral regurgitation and a ventricular septal defect.

Question 22

What causes an early vs late diastolic murmur?

Answer 22

Early: aortic regurgitation
Late: mitral stenosis, tricuspid stenosis, myxoma, and complete heart block.

Question 23

For a patient with symptomatic stable angina on a calcium channel blocker but with a contraindication to a beta-blocker, the next line treatment should be?

Answer 23

long-acting nitrate, ivabradine, nicorandil or ranolazine

Question 24

What is interval of LFT testing for statins and when should statins be stopped

Answer 24

LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range

Question 25

Which leads would represent an infarction that could cause subsequent AV block?

Answer 25

II,III, AVF (inferior) - A right coronary infarct supplies the AV node so can cause arrhythmias after infarction

Question 26

When initiating ACEi, what increase in creatinine is acceptable?
How frequently should U&E be checked after starting ACEi?

Answer 26

An increase in serum creatinine up to 30% from baseline is acceptable when initiating ACE inhibitor treatment or rise in eGFR up to 24%.
Baseline, 2 weeks after starting treatment and 2 weeks after each dose change. Once a maintenance dose has been established urea and electrolytes should be checked at 1, 3 and 6 months.

Question 27

In which group of patients is BNP not required for when suspecting HF?

Answer 27

NICE suggest that BNP measurements are not necessary for people with suspected heart failure who have had a previous myocardial infarction. These patients require an urgent referral, echocardiography and specialist assessment because if heart failure is present this carries a poor prognosis.

Question 28

What can falsely lower BNP levels?

Answer 28

Aldosterone antagonists, ACE inhibitors, angiotensin-II receptor antagonists, beta-blockers and diuretics can all falsely lower BNP levels, as can obesity.

Question 29

What is considered intermediate to high risk using the GRACE score?

Answer 29

a GRACE score >3% 6 month mortality would be classed as intermediate to high risk

Question 30

Following elective cardioversion for AF, how long is anticoagulation maintained for?

Answer 30

Lifelong, even if sinus rhythm if the CHADVASC score is medium-high risk. Can consider stopping if the score is 0.

Question 31

Which antibiotic has an important and common interaction with statins?

Answer 31

Macrolides: erythromycin/clarithromycin

Question 32

What is the main difference between dresslers syndrome and pericarditis in the context of MI?

Answer 32

Dressler’s syndrome is usually occurs 2-6 weeks post MI, whereas pericarditis is within 48hrs.

Question 33

A significant rise in creatinine after starting ACEi could be a sign of?

Answer 33

Undiagnosed bilateral renal artery stenosis

Question 34

Why is modified release isosorbide mononitrate preferred to standard?

Answer 34

Patients tend to build up a tolerance to nitrates. By providing a slow and sustained release of the modified release medication over 24 hours with a built-in nitrate-free period, it avoids continuous exposure to nitrates thereby minimising the risk of developing tolerance.

Question 35

What PPI does clopidogrel interact with?

Answer 35

Omeprazole. Patients should be switched to pantoprazole or lansoprazole

Question 36

What treatment options may be considered for acute heart failure not responding to diuretics?

Answer 36

CPAP or nitrate infusion.

Question 37

Primary prevention is used for Qrisk >10% OR…

Answer 37

Most type 1 diabetics or CKD if eGFR <60

Question 38

When would you consider titrating up primary prevention 20mg atorvastatin?

Answer 38

If non HDL has not fallen by at least 40%

Question 39

Regarding DAPT, when do we give prasugrel vs ticagrelor vs clopidogrel in addition to aspirin?

Answer 39

STEMI + PCI = Prasugrel; Ticagrelor if bleeding risk; Clopidogrel if they on an anticoagulant
STEMI + no PCI = Ticagrelor; Clopidogrel if bleeding risk or on anticoagulant
NSTEMI/Unstable angina + PCI = Prasugrel or Ticagrelor; Clopidogrel if bleeding risk or on anticoagulant
NSTEMI/Unstable angina + no PIC = Ticagrelor; Clopidogrel if bleeding risk or on anticoagulant